UPDATE: This study is currently on hold while we attend to some administrative details. Please check back to this blog often, as we will keep our readers updated.  You may also call the New Patient Coordinators at 415 834-3095 for more information.

PREVIOUSLY: Pacific Fertility Center is pleased to announce that as of October 1st we are enrolling patients into a groundbreaking research study to determine the value of combining acupuncture with IVF. Traditional

Chinese medicine has been practiced in throughout Asia for thousands of years:in the last decade, the west has been following suit.

There have been sufficient peer reviewed studies to warrant a clinical trial in which there are predictable parameters of patient involvement. One of the first studies involving acupuncture and IVF was published by Paulus et al in the journal Fertility Sterility in 2002. The Paulus study reported the influence of acupuncture on the pregnancy rate in patients who undergo assisted reproductive therapy. Clinical pregnancies were documented at 42.5% of patients in the acupuncture/IVF group, whereas pregnancy rates were 26.3% in the control group, using IVF alone. In this study, the acupuncture was performed before and after embryo transfer only.

How does acupuncture affect fertility? A review article in Alternative Therapies (Anderson 2007) suggested four possible mechanisms by which acupuncture could improve the outcome of IVF: modulatingneuroendocrine factors; increasing blood flow to the uterus and ovaries; modulating cytokines; and reducing stress, anxiety, and depression.

Pacific Fertility Center is pleased to announce the launch of our in-house mind-body medicine program. We are offering on-site acupuncture and mind-body groups to further support your treatment choices.

Over the years, Pacific Fertility Center (PFC) patients have elected to receive acupuncture treatment in combination with IVF and other fertility treatments. These treatments have been provided at outside facilities. We now offer acupuncture on-site, to minimize the stress of visiting numerous providers during your treatment cycle. We recognize that family building choices are diverse and want to support you throughout your important, personal decisions on your journey to parenthood.

This new service offers the expertise of acupuncturists who specialize in reproductive care. Our acupuncture team will work in close communication with the physicians of PFC. The result is a program that supports you with safe and convenient treatment. This exceptional new team is comprised of four licensed acupuncturists (LAc) who hold Masters of Science degrees in Traditional Chinese Medicine from accredited schools in California.

The medical team at Pacific Fertility Center is proud to provide this new service. While current studies do not show improved pregnancy rates with the combination of IVF and acupuncture treatment, we look forward to collaborative research studies to clarify these important questions. Together, we are launching exciting research projects that will investigate the scope and effectiveness of combined acupuncture and assisted reproductive technologies. Fertility Flash will provide readers with more information as the research program develops.

We hope you will enjoy getting to know the acupuncturists and take advantage of these new treatment options.

Pacific Fertility Center continues to offer the Mind/Body@PFC Workshop. At the workshop, our experienced, Alice Domar-taught instructors help patients learn healthy, positive ways to relax and decrease the symptoms of stress during their fertility treatments.

It is our hope that these offered services will provide a more comprehensive approach to your journey through fertility treatment with us at PFC.

Learn more about the acupuncture program at PFC

Every year, several Pacific Fertility Center professionals participate in ASRM’s national meeting. They evaluate the research and share their findings with PFC and Fertility Flash.

Among those attending the conference from PFC were Dr. Philip Chenette and Dr. Isabelle Ryan and Peggy Orlin, MFT. Their reviews cover the following topics: Update #1: Ovarian Stimulation Techniques, Update #2: PGD and Aneuploidy Screening Techniques, Update #3: Egg Freezing, Update #4: Acupuncture, and Update #5: Men and ART.

Update #4: Acupuncture

The published study of German Paulus ⁽¹⁾ reported improved pregnancy rates with a one-time acupuncture treatment pre-and-post embryo transfer. This sparked great interest for providers of fertility treatment, in both the conventional and Chinese medicine (TMC) communities (see Fertility Flash March, 2004). A few years later, a study from Denmark ⁽²⁾ reported improved pregnancy rates in patients receiving pre-and-post transfer acupuncture, but no improvement if there were two post-transfer treatments. In both of these studies, there were no sham acupuncture (i.e. simulated but not real acupuncture) treatment controls.

Smith ⁽³⁾ and colleagues in Australia did compare acupuncture versus sham acupuncture (but did not include a no-treatment control group), using 3 treatment sessions: ovarian stimulation day 9, pre and post embryo transfer. There was no difference found in these different study groups. Interestingly, subjects in the sham control group were more likely to report relaxation as a side effect of acupuncture. Some studies indicate that sham acupuncture evokes acupressure, and in this way, may trigger physiological responses.

In all the above studies, the acupuncture treatments were performed within the IVF centers (patients did not have to travel off-site). In general, there were no more than 100 patients per treatment group.

At ASRM, Dr. Craig and colleagues reported an acupuncture study conducted in Seattle, using 3 IVF clinics. The acupuncture sessions were performed off-site by 2 acupuncturists. The patients were randomized to pre- and post-transfer acupuncture vs. no treatment. The physicians were not aware if the subjects were or were not receiving treatment. A total of 97 patients were studied (about 50 patients per treatment group). Clinical pregnancy and live birth rates were as follows: 54% and 39% for the acupuncture group, and 78% and 65% for the control group. These results were statistically significant. Of all the acupuncture studies thus far published, this is the first study to suggest a possible detriment to the use of acupuncture in IVF treatment.

One of the important differences for this study versus other randomized controlled trials is that all the patients had to go to an off-site acupuncture center for their treatment. This may be an important factor when a patient has to travel to the acupuncture clinic immediately before and immediately after an embryo transfer. Perhaps this factor would increase stress levels. Another important difference for these Seattle IVF centers was that baseline pregnancy rates are much higher than the previously-studied non-US centers. The higher the baseline pregnancy rate, the more difficult it is to show a difference in treatment results— so a statistically significant result would be more credible.

Ideally, a multi-center randomized-controlled-trial should be performed where the following comparisons can be evaluated: acupuncture pre-and-post transfer, no-acupuncture control group, sham-acupuncture control group, and these 3 groups can be compared at both on-site and off-site acupuncture centers. Each study group would require at least 100 patients, so this would require about 1000 patients total.

As we have a chance to collaborate with TCM providers, and as patients are willing to participate in these large multi-center randomized clinical trials, we will gain a better understanding about whether a mix of allopathic and TCM medicine improves overall care, and which combination of treatments may be the most beneficial for our mutual patients.

Isabelle Ryan, MD

References:

(1) Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertil Steril. 2002, Apr; 77(4):721-4.

(2) Acupuncture on the day of embryo transfer significantly improves the reproductive outcome in infertile women: a prospective, randomized trial. Fertil Steril. 2006 May; 85(5):1341-6.

(3) Influence of acupuncture stimulation on pregnancy rates for women undergoing embryo transfer. Fertil Steril. 2006 May; 85(5):1352-8.

From time to time, PFC has visitors to the Center wishing to learn more about the field of infertility. We have had medical students from UCSF, visiting reproductive endocrinologists from Europe, and most recently, an acupuncturist studying for her doctorate in Traditional Chinese Medicine (TCM).

Heidi Kao is a licensed acupuncturist and herbalist in San Francisco and a student at the American College of Traditional Chinese Medicine, one of only 8 colleges accredited to award a doctoral degree in the U.S. She is also involved in teaching other TCM students at the college.

Her private practice is specialized in women’s health and chronic pain management, as well as an entire range of ailments. She is now interested in learning more about the Western medical approaches to infertility to better serve her infertility patients. Heidi is spending a minimum of 12 hours per month at PFC, working primarily with Dr. Givens. She is observing everything from initial consultations to ultrasound monitoring and inseminations as well as all the in vitro fertilization procedures performed at the Center. She is also spending time in the IVF laboratory, familiarizing herself with the behind-the-scenes activity of the lab.

We are also learning from Heidi. She is providing literature on the practices of TCM with regards to improving fertility. She has developed a survey for the Center in order that we might know more about how many of our patients are using complementary TCM in conjunction with their fertility treatments here. She is also involved in demonstrating her practices to the staff at the Center.

Please welcome Heidi if you see her around the office during the next few months.

Carolyn Givens, MD

PFC patients often inquire about the use of acupuncture as a part of their infertility treatment, and, as such, PFC brings you insight from Bethany Richardson M.S., L.Ac and Leslie Oldershaw, L. Ac., two Bay Area acupuncturists who integrate fertility treatment into their practices. As background, Bethany Richardson was originally a massage therapist who took a Chinese diagnosis course while working on her Shiatsu certification. That course sparked her interest in pursuing a degree in acupuncture and led her to discover her love for science and the integration of eastern and western medicine. Leslie Oldershaw entered the field of acupuncture after spending her college years dedicated to pre-med courses. She became aware of Chinese medicine as a system of treatment while in college, and it fit perfectly with her passion for eastern philosophy and culture. She had always been interested in women’s health and found that fertility treatment in Chinese medicine truly encompasses all aspects of a woman’s health. Recently, PFC interviewed Leslie and Bethany about their approach to infertility, integrative medicine, and the strengths and weaknesses of acupuncture as a fertility treatment.

PFC: When a patient first comes to you and cites infertility as the reason for their visit, what sort of initial work-up do you do?

Leslie Oldershaw: I do a very comprehensive intake that involves an interview that takes a full medical history. Depending on their history, they may have had labwork done, or I may be ordering tests. From a fertility standpoint I like to see the basic hormone panels, including a cycle day 3 FSH, TSH, Estradiol, and also a mid-luteal progesterone test. If they have done a Clomid Challenge test, I love to see those results. If they have had a HSG or an ultrasound, I like to see that as well. From a general wellness perspective, I need to see a CBC and lipid panel and a comprehensive metabolic panel. When it comes to age, if a patient is younger we can be less aggressive. If a patient is older, we will be more aggressive. If they are 30, I will do this basic work-up, but I will be more inclined to just look at how they do over the next 6 months. If someone who is 40 comes to me, I will recommend that they consult a reproductive endocrinologist. They may want to have more of an accelerated timeline in terms of their treatment options. One of the challenges that I have is that I get patients who don’t want to do the western tests. They don’t want a workup, or the partner doesn’t want to do a semen analysis. I spend a lot of time educating patients to make an informed decision rather than shooting in the dark. I will be more persuasive with my arguments as the patient gets older!

Bethany Richardson: Normally, by the time a patient sees me they have already been to a fertility expert. I ask them to bring in their most current blood work. If they have had an antral follicle count, I want to know what that is. The basal temperature chart gives me a wealth of information. I look at it more in terms of a Chinese diagnosis, not necessarily are they ovulating or when they are ovulating, which is important, but are they running too hot or too cold. It gives me a lot of subtle information from a Traditional Chinese Medicine (TCM) standpoint. If I am looking at a woman who is younger, maybe 31 or 32 years old, then I look at her history of antibiotic use and if they have a history of digestive problems. I look at her menstrual cycle, her PMS, and if she is able to detoxify her hormones correctly. If I am looking at an older woman, I look and see if she is too hot or too cold. Does she have an excess of hormones? I see people mainly when they are desperate. They come to me after two cycles of IVF and want to do everything they possibly can for the next cycle. And unfortunately, I would be more effective if I saw them earlier on, but I do what I can when patients come to me.

PFC: If a patient comes to you and she already knows she must do IVF or IUI to get pregnant, what type of protocols do you offer in conjunction with her fertility treatment?

Leslie Oldershaw: When I work with a patient leading up to the treatment cycle, there are a couple of different protocols we can utilize. The more comprehensive protocol requires 2-4 months and allows you to incorporate nutrition, acupuncture and herbal modalities. We can do a tremendous amount to build a patient up, particularly if they are coming out of a miscarriage. We also work with patients on a shorter timeline, where they might be coming in to work with us a few weeks before an IVF cycle, and then we are primarily relying mostly on acupuncture to promote good blood flow and circulation. We will talk to the patient about nutritional support, including a pre-natal vitamin and omega-3 essential fatty acids. There is not enough research at this point to use fertility medications in conjunction with herbs. If things don’t go as expected the doctor needs to be able to troubleshoot what went wrong. My feeling is that acupuncture is of benefit to everyone. The people for whom acupuncture does not work are the patients who are very needle phobic. And I have to say, my IVF patients are champs. They look at my very small needles and they scoff!

Bethany Richardson: The type of treatment depends where on the continuum they are. I look at whether or not they have done IVF before, and what the results were. Were they a poor responder? How old are they? Sometimes they come to me and they tell me their IVF cycle is in three weeks. I can’t do anything with herbs in three weeks, but I can do some acupuncture. If it is six weeks or eight weeks, then we will have a real protocol. From my perspective the hormones you inject are a very warm tonic, which can burn out your cooling system. Depending on how they react to the injectables, I might try to work with them to take some time off from IVF and load them up with cooling tonics. What I see then is that cervical mucus increases, sleeping patterns regulate and stress levels go down. It’s hard for me to prove that it works, but I honestly believe that it does. Stress management, diet, acupuncture and IVF combined can add up to a much greater level of success.

PFC: What are the strengths and weaknesses of using acupuncture to treat infertility?

Bethany Richardson: It regulates the hormones, helps detoxify the body so you don’t have systemic inflammation, reduces PMS and pain. I think its only downfall is that it takes time. And a lot of the time—women aren’t willing to wait. And that’s where I come in again and say, it’s not a sprint, it’s a marathon. Acupuncture isn’t a golden pill. If you continue to eat poorly and not give your body good nutrients and antioxidants, then I can’t do as much.

PFC: Is there anything you want to add about treating infertility with acupuncture?

Leslie Oldershaw: I have always been keen on integrative approaches. There is a tremendous amount that western medicine can do to help people achieve a pregnancy. But what makes a critical difference for me is the integrative approach. What I am doing with my patients is different than what a Reproductive Endocrinologist does, but together we can work synergistically to create the best outcome.

Bethany Richardson: I am very excited about the future. I am hoping that eventually there will be research money that is earmarked for this arena. Often times acupuncture is seen as competitive with western medicine, and I don’t think it has to be. If we join forces we can be more effective together.

More and more patients undergoing fertility treatment ask about incorporating acupuncture and Chinese herbal medicine treatment with their IVF cycle. Some patients are especially inquisitive after reading Lifang Liang’s recently published book Acupuncture and IVF: Increase IVF Success by 40-60%. For most patients going through the struggle of infertility, this title proposes a provocative and enticing claim.

While acupuncture is based on an ancient medical tradition, current studies are trying to clarify the physiological basis for treatment results. Some indicate that the benefits of acupuncture may be mediated by opioid-types of proteins in the central nervous system. Some of the proteins affect gonadotropin secretion from the pituitary (brain), and therefore could impact menstrual cyclicity to help regulate ovulation. Others propose that blood flow to the pelvic organs may be improved through mechanisms other than the central nervous system therefore improving fertility. And yet others propose there might be a psychosomatic benefit.

While all these theories are intriguing, a true understanding of the benefit of acupuncture and its impact on fertility will not be elucidated until the execution of several well designed studies (large numbers of patients, randomized controlled trials).

To date, there is only one such study (Paulus et al, Fertil Steril. 2002 Apr;77(4):721-4), which was conducted in Germany. While this study revealed an improvement in pregnancy rates, there are a number of issues with the study itself, which calls for cautious interpretation of the final results (an improvement in pregnancy rates from 26% to 42% – 61.5% improvement rate). For instance, the study was weakened by a low baseline pregnancy rate (26.3%) in a young patient population (early 30yo). Statistically, it is much easier to show an improvement in pregnancy rate, when the baseline pregnancy rate is so low. This finding may not hold true if this study was performed in an IVF center where the pregnancy rates in young patients was closer to 50% (which is what we expect for patients in their early 30s). More importantly, when studying such complex questions, a clear understanding will not be obtained, and claims of improvement cannot be made, until a number of well designed studies are performed and the majority of results echo a similar theme (either positive or negative).

In her book, Lifang Liang presents a nice overview of the theories behind Chinese Medicine, as well as various herbal treatments available for fertility patients, and their proposed effects. She then presents a number of “Case Histories”, illustrating the use of both herbal therapies and acupuncture. While these are quite interesting, they are anecdotal stories, and do not represent a scientific study to evaluate the role of acupuncture and infertility. The above study by Paulus et al is mentioned in the book, and seems to be the basis for the claim of a 40-60% increase in IVF success rates. As mentioned, this claim should be taken with caution.

All of us who serve patients with fertility treatment, whether trained in Western or Chinese medicine, are looking for the best possible outcome for our patients. It would be wonderful if indeed there was a combination of various treatment approaches which, when practiced together, could provide the best “cocktail”. However, the exact role that acupuncture plays is currently an unanswered question, until more well-designed studies are performed. We look forward to such studies, to better define the role of acupuncture and herbal remedies in the treatment of infertility.

Acupuncture, one of the world’s oldest and most established healing practices, is growing in popularity as a way to complement the modern procedures of ART – Assisted Reproductive Technologies. Although the scientific evidence behind acupuncture is scanty, belief in this technique is so strong, some patients having just undergone implantation after IVF will head straight to their TCM (Traditional Chinese Medicine) practitioner for an immediate acupuncture treatment.

Acupuncture is just one component of Traditional Chinese Medicine (TCM), which also involves herbs, pelvic massages and dietary adjustments to garner a “whole body” systems approach to health. Following a track record of over 4000 years, nearly one quarter of the world’s population turns to TCM for their primary heath care. In Western societies, acupuncture is frequently cited as providing almost instantaneous relief to debilitating ailments such as bad backs and sports injuries.

Tiny sterilized needles are inserted into key points of the body and left there for 20-30 minutes. Barely felt, the needles reportedly open up Qi (pronounced Chee), which is vital energy defined by increased blood flow and the benefits of the body’s systems working together to break down so-called blockages.

Only two scientific research studies have examined the benefits of acupuncture with IVF treatment. The most talked about was reported in the journal Fertility & Sterility, April 2002 (Vol. 77, No.4) involving 160 IVF patients in Germany. Half of them underwent acupuncture before and after embryo transfer and the other half served as the control group. 34 out of the 80 women who received acupuncture revealed clinical pregnancies (42.5 %), whereas, 21 out of 80 women in the control group became clinically pregnant (26.1%).

Although the physiological mechanisms are not fully understood, it is believed that acupuncture optimizes endometrial receptivity and enhances blood flow to the pelvic area. According to TCM principles, energy flows through the body along pathways, or meridians. Acupuncture is a means of enhancing this energy and coaxing the body’s responses to induce a desired physiological effect. Ideally, according to TCM practitioners, women should undergo acupuncture treatment 3-4 months prior to an IVF cycle instead of as a last minute flurry.

We at PFC encourage our patients who inquire about acupuncture to pursue it, and we provide a list of Bay Area TCM practitioners who are certified by the National Acupuncture and Oriental Medicine Alliance and licensed by the state of California. (UPDATE: PFC now provides in-house acupuncture services.) However, under no circumstance do we condone the use of herbal supplements that are sometimes provided with acupuncture for women undergoing infertility treatment at PFC. Most TCM practitioners agree with this approach, and will communicate your treatment protocol with our physicians here at PFC.